<h2 class="name-el"/>
<h3 class="title-el"/>
<form role="form">
    <div class="row">
        <div class="form-group col-xs-6">
            <label for="evaluation-date">Data</label>
            <input id="evaluation-date" name="date" type="text" class="form-control" readonly/>
            <span class="help-block hidden"></span>
        </div>
        <div class="form-group col-xs-6">
            <label for="evaluation-shiftid">Turno</label>
            <select id="evaluation-shiftid" name="shiftid" class="form-control"></select>
            <span class="help-block hidden"></span>
        </div>
    </div>
    <div class="row">
    <div class="form-group col-md-4">
        <label for="evaluation-rass">RASS</label>
        <select id="evaluation-rass" name="rass" class="form-control"></select>
        <span class="help-block hidden"></span>
    </div>
    </div>
    <div class="row">
    <div class="form-group col-md-4">
        <label for="evaluation-deliriumid">Delirium</label>
        <select id="evaluation-deliriumid" name="deliriumid" class="form-control"></select>
        <span class="help-block hidden"></span>
    </div>
    </div>
    <div class="row">
        <div class="form-group col-md-4">
        <label for="evaluation-ventilationid">Ventilação</label>
        <select id="evaluation-ventilationid" name="ventilationid" class="form-control"></select>
            <span class="help-block hidden"></span>
       </div>
    </div>


    <div class="row">
        <div class="form-group col-md-4">
            <label>Sedação</label>
            <div class="checkbox">
            <label><input type="checkbox" name="nosedation" value="7"/>Sem sedação</label>
            </div>
            <input type="hidden" name="nosedation" value="7"/>
            <div class="checkbox">
            <label><input type="checkbox" name="sedation" value="1"/>Propofol</label>
            </div>
            <div class="checkbox">
            <label><input type="checkbox" name="sedation" value="2"/>Midazolam</label>
            </div>
            <div class="checkbox">
            <label><input type="checkbox" name="sedation" value="3"/>Fentanil</label>
            </div>
            <div class="checkbox">
            <label><input type="checkbox" name="sedation" value="4"/>Cetamina</label>
            </div>
            <div class="checkbox">
            <label><input type="checkbox" name="sedation" value="6"/>Dexmetomedina</label>
            </div>
        </div>
   </div>

    <div class="row">
        <div class="form-group col-md-4">
            <label>ICDSC</label>
            <div class="checkbox">
                <label><input type="checkbox" name="icdsc" value="1"/>Nível de consciência alterado</label>
            </div>
            <div class="checkbox">
                <label><input type="checkbox" name="icdsc" value="2"/>Inatenção</label>
            </div>
            <div class="checkbox">
                <label><input type="checkbox" name="icdsc" value="3"/>Desorientação</label>
            </div>
            <div class="checkbox">
                <label><input type="checkbox" name="icdsc" value="4"/>Alucinação/Delírio/Psicose</label>
            </div>
            <div class="checkbox">
                <label><input type="checkbox" name="icdsc" value="5"/>Retardo ou agitação motora</label>
            </div>
            <div class="checkbox">
                <label><input type="checkbox" name="icdsc" value="6"/>Fala ou humor inapropriado</label>
            </div>
            <div class="checkbox">
                <label><input type="checkbox" name="icdsc" value="7"/>Ciclo de sono e vigília alterado</label>
            </div>
            <div class="checkbox">
                <label><input type="checkbox" name="icdsc" value="8"/>Flutuação de sintoma</label>
            </div>
        </div>
    </div>
</form>
<hr/>
<div class="alert alert-danger hidden" role="alert"></div>
<button type="button" class="btn btn-default cancel">Cancelar</button>
<button type="button" class="btn btn-primary save-model">Salvar</button>

